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OP Registration
Patient Details
  
Basic Information
Name: * Mobile No.: *
Date Of Birth: (or) * Gender: * Addnl Phone:
Next Of Kin Name: Relation: Contact No.:
Patient Category: Case File:
Additional Patient Information
Address: Area:
State:
  City:
*
Country:
Custom List 1: * Custom List 2: Custom List 4:
Custom List 5: Custom List 6: Custom List 7:
Custom List 8: Custom List 9: Email ID:
Govt Identifier Label EMIRATE ID
Remarks: Email Id: PMOre:
Additional Visit INformation
Visit Custom List 1: * Visit Custom List 2: Outside MR Number:
Sponsor Information
Primary Sponsor: Secondary Sponsor:
Primary Sponsor
Insurance Co:
TPA: Approved Amt:
Network/Plan Type: Plan Name: Plan Details:
Membership ID:
Validity Start: Validity End:
Policy Number: Policy Holder: Relationship:
Prior Auth No: Prior Auth Mode:
Document Upload: Paste Image:
Payment Information
Bill Type:
Visit Information
Department: * Transferred From:
Consulting Doctor:
Visit Type: Consultation Type:
Consultation Time: Consultation Remarks: Consultation Fees:
Referred By:
*
Complaint:

Orders
Date/Time Prescribed By Type Item Details Remarks Amount Pat. Amt
Pri Prior Auth
Total Amount:
Payment Mode: Cash Payment Remarks:
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  • TRIAGE: Tobacco Usage Info Collection also be part of Triage Process. Height, Weight, BP Diastolic & Systolic are mandated vital fields As HAAD made it as mandatory on January 2012
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